Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause

Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause : A Systematic Review

BACKGROUND

Postmenopausal women commonly experience vulvovaginal, urinary, and sexual symptoms associated with genitourinary syndrome of menopause (GSM).

PURPOSE

To evaluate effectiveness and harms of vaginal estrogen, nonestrogen hormone therapies, and vaginal moisturizers for treatment of GSM symptoms.

DATA SOURCES

Medline, Embase, and CINAHL through 11 December 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) of at least 8 weeks' duration enrolling postmenopausal women with at least 1 GSM symptom and reporting effectiveness or harms of hormonal interventions or vaginal moisturizers.

DATA EXTRACTION

Risk of bias and data extraction were performed by one reviewer and verified by a second reviewer. Certainty of evidence (COE) was assessed by one reviewer and verified by consensus.

DATA SYNTHESIS

From 11 993 citations, 46 RCTs evaluating vaginal estrogen (k = 22), nonestrogen hormones (k = 16), vaginal moisturizers (k = 4), or multiple interventions (k = 4) were identified. Variation in populations, interventions, comparators, and outcomes precluded meta-analysis. Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Compared with placebo, vaginal dehydroepiandrosterone (DHEA) may improve dryness, dyspareunia, and distress, bother, or interference from genitourinary symptoms; oral ospemifene may improve dryness, dyspareunia, and treatment satisfaction; and vaginal moisturizers may improve dryness (all low COE). Vaginal testosterone, systemic DHEA, vaginal oxytocin, and oral raloxifene or bazedoxifene may provide no benefit (low COE) or had uncertain effects (very low COE). Although studies did not report frequent serious harms, reporting was limited by short-duration studies that were insufficiently powered to evaluate infrequent serious harms.

LIMITATIONS

Most studies were 12 weeks or less in duration and used heterogeneous GSM diagnostic criteria and outcome measures. Few studies enrolled women with a history of cancer.

CONCLUSION

Vaginal estrogen, vaginal DHEA, oral ospemifene, and vaginal moisturizers may improve some GSM symptoms in the short term. Few long-term data exist on efficacy, comparative effectiveness, tolerability, and safety of GSM treatments.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42023400684).

Oral lasofoxifene's effects on moderate to severe vaginal atrophy in postmenopausal women: two phase 3, randomized, controlled trials

OBJECTIVE

The aim of this study was to demonstrate whether lasofoxifene improves vaginal signs/symptoms of genitourinary syndrome of menopause.

METHODS

Two identical, phase 3 trials randomized postmenopausal women with moderate to severe vaginal symptoms to oral lasofoxifene 0.25 or 0.5 mg/d, or placebo, for 12 week. Changes from baseline to week 12 in most bothersome symptom, vaginal pH, and percentages of vaginal parabasal and superficial cells were evaluated. These coprimary endpoints were analyzed using analysis of covariance, except superficial cells, which were analyzed by the nonparametric, rank-based Kruskal-Wallis test.

RESULTS

The two studies enrolled 444 and 445 women (mean age, ~60 y), respectively. Coprimary endpoints at week 12 improved with lasofoxifene 0.25 and 0.5 mg/d greater than with placebo ( P < 0.0125 for all). Study 1: most bothersome symptom (least square mean difference from placebo: -0.4 and -0.5 for 0.25 and 0.5 mg/d, respectively), vaginal pH (-0.65, -0.58), and vaginal superficial (5.2%, 5.4%), and parabasal (-39.9%, -34.9%) cells; study 2: most bothersome symptom (-0.4, -0.5), vaginal pH (-0.57, -0.67), and vaginal superficial (3.5%, 2.2%) and parabasal (-34.1%, -33.5%) cells. Some improvements occurred as early as week 2. Most treatment-emergent adverse events were mild or moderate and hot flushes were most frequently reported (lasofoxifene vs placebo: 13%-23% vs 9%-11%). Serious adverse events were infrequent and no deaths occurred.

CONCLUSIONS

In two phase 3 trials, oral lasofoxifene 0.25 and 0.5 mg/d provided significant and clinically meaningful improvements in vaginal signs/symptoms with a favorable safety profile, suggesting beneficial effects of lasofoxifene on genitourinary syndrome of menopause.

Managing menopause after cancer

Globally, 9 million women are diagnosed with cancer each year. Breast cancer is the most commonly diagnosed cancer worldwide, followed by colorectal cancer in high-income countries and cervical cancer in low-income countries. Survival from cancer is improving and more women are experiencing long-term effects of cancer treatment, such as premature ovarian insufficiency or early menopause. Managing menopausal symptoms after cancer can be challenging, and more severe than at natural menopause. Menopausal symptoms can extend beyond hot flushes and night sweats (vasomotor symptoms). Treatment-induced symptoms might include sexual dysfunction and impairment of sleep, mood, and quality of life. In the long term, premature ovarian insufficiency might increase the risk of chronic conditions such as osteoporosis and cardiovascular disease. Diagnosing menopause after cancer can be challenging as menopausal symptoms can overlap with other common symptoms in patients with cancer, such as fatigue and sexual dysfunction. Menopausal hormone therapy is an effective treatment for vasomotor symptoms and seems to be safe for many patients with cancer. When hormone therapy is contraindicated or avoided, emerging evidence supports the efficacy of non-pharmacological and non-hormonal treatments, although most evidence is based on women older than 50 years with breast cancer. Vaginal oestrogen seems safe for most patients with genitourinary symptoms, but there are few non-hormonal options. Many patients have inadequate centralised care for managing menopausal symptoms after cancer treatment, and more information is needed about cost-effective and patient-focused models of care for this growing population.

An empowerment model for managing menopause

Menopause eventually happens to all people with typically functioning ovaries, and almost one billion women worldwide are postmenopausal. Although the biology of typical menopause is ubiquitous, the experience varies substantially. Factors contributing to the experience include not only individual factors, such as the nature and severity of symptoms, but also psychological, social, and contextual considerations, many of which are modifiable. In this first paper in the Lancet Series on menopause, we argue for a new approach that goes beyond the treatment of specific symptoms, to encompass a broad model to support women transitioning this life stage, using the model of empowerment. WHO defines empowerment as an active process of gaining knowledge, confidence, and self-determination to self-manage health and make informed decisions about care. Rather than focusing on menopause as an endocrine deficiency, we propose an empowerment model that recognises factors modifying the experience, in which the patient is an expert in their own condition and the health-care worker supports the patient to become an equal and active partner in managing their own care.

Androgen-based therapies in women

Androgens play a key biological role in libido and sexual arousal in women, and knowledge about their complex role in other systems remains ambiguous and incomplete. This narrative review examines the role of endogenous androgens in women's health throughout the life span before focusing on evidence surrounding the use of androgen-based therapies to treat postmenopausal women. The role of testosterone as a therapeutic agent in women continues to attract controversy as approved preparations are rare, and use of off-label and compounded formulations is widespread. Despite this androgen therapy has been used for decades in oral, injectable, and transdermal formulations. Responses to androgen therapy have been demonstrated to improve aspects of female sexual dysfunction, notably hypoactive sexual desire disorder, in a dose related manner. Substantial research has also been conducted into the role of androgens in treating aspects of the genitourinary syndrome of menopause (GSM). Evidence for benefits beyond these is mixed and more research is required regarding long-term safety. However, It remains biologically plausible that androgens will be effective in treating hypoestrogenic symptoms related to menopause, either through direct physiological effects or following aromatization to estradiol throughout the body.

A systematic review of randomised clinical trials - The safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors

Therapies utilised in breast cancer management have been found to induce or worsen the genitourinary symptoms of menopause (GSM), a group of physical symptoms associated with the systemic loss of estrogen. These symptoms are often undertreated due to concerns surrounding cancer recurrence, especially when considering treatments with possible pro-estrogenic effects. As breast cancer prognosis continues to improve, clinicians are increasingly focussing on managing these symptoms amongst survivors. This systematic review primarily aimed to determine the risk of breast cancer recurrence amongst survivors using vaginal hormones and selective estrogen receptor modulator therapies recommended for use in GSM in the United Kingdom amongst currently published randomised clinical trials (RCTs). The secondary aim was to determine whether these RCTs demonstrated a significant rise in serum estrogen levels following the use of these therapies. A literature search revealed three RCTs suitable for assessment, two evaluating vaginal estrogen and one evaluating vaginal DHEA treatment. Our review determined that amongst published RCTs, no studies have aimed to assess for breast cancer recurrence; however among the studies observing for serious adverse effects of vaginal estrogen preparations, none have reported an increased incidence. Furthermore, these studies did not report a persistent or significant increase in serum estrogen levels following the use of vaginal estrogen products and low concentration (3.25 mg/day) DHEA gel. Larger RCTs studying commonly used vaginal preparations and selective estrogen receptor modulator treatments for GSM over longer follow-up periods will be vital to better assess the risk of breast cancer recurrence in survivors receiving these treatments.

Vaginal health and quality of sexual life of postmenopausal women on hyaluronic acid and Biosaccharide Gum-1 vaginal gel

OBJECTIVE

To evaluate the efficacy of daily vaginal gel containing hyaluronic acid (HA) and Biosaccharide Gum-1 (BG-1) on vulvovaginal atrophy (VVA) and on sexual function and quality of life (QoL).

MATERIALS AND METHODS

One hundred-four postmenopausal women with VVA were enrolled in the nonrandomized comparison cohort study. Of them, 50 women on HA/BG-1 participated in the study group and 54 women on lubricants/moisturizers on-demand as a control group. The primary endpoint was the efficacy of the vaginal gel on VVA evaluated by the Vaginal Health Index (VHI) score. Secondary endpoints included sexual behavior by the self-administered female sexual function index (FSFI) questionnaire, and quality of life (QoL), by the Short Form-36 questionnaire (SF-36).

RESULTS

All symptoms of AVV improved after 12 weeks of treatment in women on HA/BG-1. The VMI, although improved at the 12-week follow-up compared to baseline, it connoted a low estrogenic stimulation value. Sexual function improved significantly in women on HA/BG-1. Moreover, women reported a significant improvement in the somatic aspects of QoL. No benefits were obtained by the women in the control group.

CONCLUSIONS

Treatment with HA/BG-1 could have used in postmenopausal women who complain of vaginal dryness. The amelioration of VVA-related signs could improve sexual function and QoL.

Reduction in genital sexual arousal varies by type of oral contraceptive pill

BACKGROUND

Although oral contraceptive pills (OCPs) have been associated with decrements in self-reported genital arousal and vaginal lubrication, 1,2 little is known about how these outcomes vary across types of OCPs.

AIM

The present study examined differences in physiological lubrication and vaginal blood flow, as well as rates of self-reported vulvovaginal atrophy and female sexual arousal disorder, among women using OCPs with varying androgenic properties.

METHODS

Participants in this study were 130 women: 59 naturally cycling control women, 50 women taking androgenic OCPs, and 21 women taking antiandrogenic OCPs. Participants watched sexual films while their sexual arousal responses were measured, completed questionnaires, and participated in a clinical interview.

OUTCOMES

Vaginal blood flow, vaginal lubrication, self-reported vulvovaginal atrophy, and female sexual arousal disorder were assessed.

RESULTS

Results indicated deficits in vaginal pulse amplitude and lubrication for women taking either form of OCP, with marked inhibitory effects found in women taking antiandrogenic OCPs. Rates of self-reported vulvovaginal atrophy and female sexual arousal disorder were also significantly greater in the antiandrogenic group compared with the control group.

CLINICAL IMPLICATIONS

It is recommended that prescribing clinicians consult patients on such physiological effects of OCPs.

STRENGTHS AND LIMITATIONS

To our knowledge, this was the first study to compare multiple measures of physiological sexual arousal across groups of women taking OCPs with varying hormonal profiles. Because all OCPs included in this study contained low doses of ethinylestradiol, we were able to identify the specific effects of the androgenic properties on women's sexual arousal responses. However, the self-administered lubrication test strip was subject to user error. Additionally, the generalizability of findings is limited by the largely heterosexual and college-aged sample.

CONCLUSION

Compared with naturally cycling women, women taking OCPs that contain antiandrogenic progestins experienced decreased vaginal blood flow and lubrication as well as higher rates of self-reported vaginal bleeding and female sexual arousal disorder.

Efficacy, tolerability, and endometrial safety of ospemifene compared with current therapies for the treatment of vulvovaginal atrophy: a systematic literature review and network meta-analysis

IMPORTANCE

Ospemifene is a novel selective estrogen receptor modulator developed for the treatment of moderate to severe postmenopausal vulvovaginal atrophy (VVA).

OBJECTIVE

The aim of the study is to perform a systematic literature review (SLR) and network meta-analysis (NMA) to assess the efficacy and safety of ospemifene compared with other therapies used in the treatment of VVA in North America and Europe.

EVIDENCE REVIEW

Electronic database searches were conducted in November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or nonrandomized controlled trials targeting postmenopausal women with moderate to severe dyspareunia and/or vaginal dryness and involving ospemifene or at least one VVA local treatment were considered. Efficacy data included changes from baseline in superficial and parabasal cells, vaginal pH, and the most bothersome symptom of vaginal dryness or dyspareunia, as required for regulatory approval. Endometrial outcomes were endometrial thickness and histologic classifications, including endometrial polyp, hyperplasia, and cancer. For efficacy and safety outcomes, a Bayesian NMA was performed. Endometrial outcomes were compared in descriptive analyses.

FINDINGS

A total of 44 controlled trials met the eligibility criteria (N = 12,637 participants). Network meta-analysis results showed that ospemifene was not statistically different from other active therapies in most efficacy and safety results. For all treatments, including ospemifene, the posttreatment endometrial thickness values (up to 52 wk of treatment) were under the recognized clinical threshold value of 4 mm for significant risk of endometrial pathology. Specifically, for women treated with ospemifene, endometrial thickness ranged between 2.1 and 2.3 mm at baseline and 2.5 and 3.2 mm after treatment. No cases of endometrial carcinoma or hyperplasia were observed in ospemifene trials, nor polyps with atypical hyperplasia or cancer after up to 52 weeks of treatment.

CONCLUSIONS AND RELEVANCE

Ospemifene is an efficacious, well-tolerated, and safe therapeutic option for postmenopausal women with moderate to severe symptoms of VVA. Efficacy and safety outcomes with ospemifene are similar to other VVA therapies in North America and Europe.

Diagnosis, causes, and treatment of dyspareunia in postmenopausal women

IMPORTANCE AND OBJECTIVES

Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women.

METHODS

This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia.

FINDINGS

Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists.

CONCLUSIONS

Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.

Genitourinary Syndrome of Menopause

Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on prescription treatments and adjunctive therapies.

The Current Strategy in Hormonal and Non-Hormonal Therapies in Menopause—A Comprehensive Review

Menopause is a natural stage of hormonal aging in women, accompanied by a series of symptoms that reduce the quality of life of a fully active person. As no therapy is entirely satisfactory, the race for a better option is in full swing. Our study objective is to investigate the most recent menopause studies on pharmacological resources, emerging therapies, and the particularities of hormonal replacement therapy (HRT). For this purpose, a comprehensive search was conducted in two main databases (PubMed and Web of Science) guided by the specific keywords “menopause” and “therapy” or “estrogen” or “progesterone” or “hormone replacement” during the last ten years period. Studies were eligible if they met certain criteria: randomized controlled trials (RCT) in adult women with menopause and hormonal or non-hormonal therapies. We selected 62 RCTs, which are focused on four main topics: (a) epidemiology of menopause-related symptoms, (b) hormonal replacement therapy (HRT) selective estrogen receptor modulators, (c) emerging therapies, and (d) menopause. HRT has proven a real health benefit for menopausal women; besides, complementary interventions must be considered. Further studies are needed on menopause and menopause-related therapies. The continuous updating of clinical experience will strengthen the therapeutic benefit and the decision to treat patients safely. This goal will fully access all therapeutic resources to address an unresolved health issue of active adult women.

Management of Menopausal Symptoms: A Review

IMPORTANCE

Menopause, due to loss of ovarian follicular activity without another pathological or physiological cause, typically occurs between the ages of 45 years and 56 years. During the menopausal transition, approximately 50% to 75% of women have hot flashes, night sweats, or both (vasomotor symptoms) and more than 50% have genitourinary symptoms (genitourinary syndrome of menopause [GSM]).

OBSERVATIONS

Vasomotor symptoms typically last more than 7 years and GSM is often chronic. Efficacious treatments for women with bothersome vasomotor symptoms or GSM symptoms include hormonal and nonhormonal options. Systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75%. Oral and transdermal estrogen have similar efficacy. Conjugated equine estrogens (CEE) with or without medroxyprogesterone acetate (MPA) were the only hormonal treatments for which clinical trials were designed to examine cardiovascular events, venous thromboembolism, and breast cancer risk. Compared with placebo, the increased risk of stroke and venous thromboembolism associated with CEE (with or without MPA) and breast cancer (with use of CEE plus MPA) is approximately 1 excess event/1000 person-years. Low-dose CEE plus bazedoxifene is not associated with increased risk of breast cancer (0.25%/year vs 0.23%/year with placebo). Bioidentical estrogens approved by the US Food and Drug Administration (with identical chemical structure to naturally produced estrogens, and often administered transdermally) also are available to treat vasomotor symptoms. For women who are not candidates for hormonal treatments, nonhormonal approaches such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine are available and are associated with a reduction in frequency of vasomotor symptoms by approximately 40% to 65%. Low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80%, with improvement in severity by 40% to 80% for vaginal prasterone, and with improvement in severity by 30% to 50% for oral ospemifene.

CONCLUSIONS AND RELEVANCE

During the menopausal transition, approximately 50% to 75% of women have vasomotor symptoms and GSM symptoms. Hormonal therapy with estrogen is the first-line therapy for bothersome vasomotor symptoms and GSM symptoms, but nonhormonal medications (such as paroxetine and venlafaxine) also can be effective. Hormone therapy is not indicated for the prevention of cardiovascular disease.

[Efficacy and safety of testosterone in the treatment of hypoactive sexual desire in women: what does the evidence say?]

OBJECTIVE

To determine the efficacy and safety of testosterone in the treatment of hypoactive sexual desire in women.

MATERIALS AND METHODS

A systematic review of the literature was carried out in different electronic databases (CINAHL, DynaMed, EMBASE, Lilacs, Medline, Scopus, among others), between January 1990 and May 2021; through standardized search terms. The outcomes evaluated included the efficacy and safety of testosterone in increasing sexual desire, the total number of satisfactory sexual activity, the number of orgasms and the level of distress in patients with hypoactive sexual desire and the proportion of adverse reactions.

RESULTS

72 articles were included. The use of testosterone, in postmenopausal women, with hypoactive sexual desire, reports a positive effect on sexual function, with significant increases in satisfactory sexual activity, as well as improvement in all domains of sexual function (desire, arousal and orgasmic response) and a decrease in personal anguish, with an increase in the Female Sexual Function Index score. In women of childbearing age, testosterone is formulated for "off-label" use, in such a way that compounds and doses designed for treatments in men or magisterial formulas are used (which are not approved by consensus groups or endorsed by research), but has not shown any effect on sexual function. The most frequent adverse reactions are usually hirsutism and acne, although in general testosterone, at physiological doses, has a favorable safety profile.

CONCLUSIONS

Testosterone is an effective and safe therapy in the treatment of hypoactive sexual desire disorder in women after menopause. Currently there are no studies available to support the use of testosterone therapy in women of reproductive age, therefore, its use is not approved.

Drugs for the treatment of postmenopausal symptoms: Hormonal and non-hormonal therapy

Postmenopausal symptoms are systemic symptoms associated with estrogen deficiency after menopause. At present, treatments for postmenopausal symptoms include hormonal therapy (HT) and non-HT. However, the optimal regimen for balancing the benefits and risks remains unclear. This article reviewed the characteristics, regimens, and side effects of drugs used in hormonal and non-HT. However, HT is still the most effective treatment with safety in early initiation since menopause onset. Nevertheless, it is essential to evaluate the risks of related chronic diseases and customize individualized treatments. Possible estetrol preparations and more types of Tissue Selective Estrogen Complex formulations are potential directions of drug development in the future of HT. Regarding non-HT, fezolinetant, currently in phase III clinical trials, is poised to become a first-in-class therapy for vasomotor symptoms. Ospemifene, dehydroepiandrosterone (DHEA), and vaginal lasers can also be used for moderate-to-severe genitourinary syndrome of menopause. Recent data suggest a superior efficacy and safety of vaginal lasers, but more validated evidence of long-term tolerability is needed to respond to the United States Food and Drug Administration warning. Herbal medication commonly used in Asia is effective in alleviating menopausal symptoms; however, its adverse effects still require more detailed reports and standardized observation methods. This review contributes to a better understanding of drugs for the treatment of postmenopausal symptoms and provides useful information for clinical drug selection.

Management of Menopause Symptoms and Quality of Life during the Menopause Transition

Some women experience bothersome symptoms around the time of menopause that may have a negative impact on their quality of life and prompt them to seek treatments. Menopausal hormone therapy was historically the treatment of choice. However, medical contraindications and personal preference for nonhormonal therapy have prompted the evaluation of a range of nonhormonal pharmacologic and non-pharmacologic therapies. This review provides an update focusing on the latest evidence-based approach for the management of bothersome symptoms of menopause.

Treatment of Sexual Dysfunction in Women with Systemic Autoimmune Rheumatic Disorders: A Systematic Review

Introduction

Female sexual dysfunction (SD) is an under-recognized and undertreated problem in patients with systemic autoimmune rheumatic disorders (SARDs).

Objectives

To summarize and evaluate the existing treatment modalities for SD in females with SARDs.

Methods

A systematic review was conducted following the PRISMA guidelines. Electronic databases were searched up to April 2022 for studies that assessed the use of pharmacological and non-pharmacological treatment modalities for the management of SD in females with SARDs. Randomized and observational studies were included. (PROSPERO: CRD42022296381).

Results

Seven studies with 426 females with SD were included. Seven different treatment modalities belonging to 5 different classes (androgen therapy, phosphodiesterase-5 inhibitors, exercise, education and local creams) were evaluated in patients with systemic lupus erythematosus, rheumatoid arthritis and systemic sclerosis. The majority of the studies were of low methodological quality. Standardized patient education and 8-week aerobic walking programs were successful in improving female SD. Local creams improved dyspareunia in females with systemic sclerosis. Testosterone did not significantly improve SD in patients with systemic lupus erythematosus. Accordingly, tadalafil did not result in a significant improvement of SD in females with systemic sclerosis, based on the Female Sexual Function Index.

Conclusion

There is a lack of sufficient evidence to recommend a certain management strategy for SD in females with SARDs. Nonpharmacological therapy and lubricant creams may be beneficial in females with SARDs. No benefit was demonstrated after androgen therapy or tadalafil. Still, no definite conclusions can be drawn due to the important limitations of the available literature. Overall, our results may be considered preliminary and further research in the field is mandatory.

Short-Term Efficacy and Safety of Non-Ablative Laser Treatment Alone or with Estriol or Moisturizers in Postmenopausal Women with Vulvovaginal Atrophy

BACKGROUND

Among treatments for vulvo-vaginal atrophy (VVA), there is a new kind of energy-based device, the non-ablative CO2 laser.

AIM

This study aimed to assess the efficacy and safety of the non-ablative CO2 laser in menopausal women with VVA as a monotherapy or in association with vaginal estriol or moisturizer.

METHODS

Seventy-five women with VVA received laser treatment (Laser group), laser plus estriol gel (Laser+E) or laser plus moisturizers (Laser+M). The study protocol consisted of 3 monthly laser sessions (t0, t1, t2) and a gynecological examination at baseline and 1 month after last laser treatment (t3). Objective measures included VHI (Vaginal Health Index) and VuHI (Vulvar Health Index); subjective symptoms of VVA (Dryness, Burning, Itching, Dysuria) evaluated via visual analog scales, sexual function evaluated by FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Score) and MENQOL (Mopause-specific Quality Of Life). Adverse events and discomfort encountered during the procedure were also assessed.

OUTCOMES

Primary outcomes were the evaluation of VHI and VuHI and secondary outcomes were changes in VVA symptoms (VAS), sexual function (MENQOL, FSFI, FSDS) and discomfort during the procedure.

RESULTS

Seventy-five women (25 in Laser, 25 in Laser+E and 25 in Laser+M group) completed the study. At t3, mean VHI, VuHI, dryness, burning and itching VAS scores improved significantly with no differences between the groups. The lubrication domain of FSFI improved significantly only in the Laser+M group, while the pain domain improved significantly in all women with no differences between the groups. FSFI and FSDS overall scores and MENQOL sexual domain improved in all women with no significant difference between the groups. The mean score of the pain during the procedure was low at t0 and did not change throughout the study.

CLINICAL IMPLICATIONS

This study extends knowledge concerning the effectiveness of a new non-ablative CO2 laser in post-menopausal women with VVA.

STRENGTHS & LIMITATIONS

This is one of the first studies on this kind of laser and is the first to compare the effectiveness of laser treatment alone or in combination with vaginal estriol or moisturizers. Parameters of VVA and sexual function were evaluated using validated tools. Study limitations include short follow-up time, the limited number of participants and the absence of a sham-controlled group.

CONCLUSION

Non-ablative CO2 laser seems to be an effective treatment for VVA in menopausal women. Our preliminary data shows that it can be effective as monotherapy or with adjuvant treatments. Alvisi S, Lami A, Baldassarre M, et al. Short-Term Efficacy and Safety of Non-Ablative Laser Treatment Alone or with Estriol or Moisturizers in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2022;19:761-770.

Efficacy of interventions to manage sexual dysfunction in women with cancer: a systematic review

IMPORTANCE

Cancer and its treatment negatively affect female sexual health and function. The prevalence of female sexual dysfunction after cancer is between 33% and 43%. Numerous studies have addressed treatment options for sexual dysfunction in women with cancer, but it still remains a challenge to select the most efficacious option for patients.

OBJECTIVE

To compile and appraise recent evidence of any interventions for managing sexual dysfunction in female cancer survivors.

EVIDENCE REVIEW

A literature search of the electronic databases MEDLINE, EMBASE, PsycINFO, and Cochrane Central Register of Controlled Trials (January 2011 to February 2021) was conducted using general search terms of "women", "cancer", "intervention", "sexual dysfunction". We included randomized controlled trials (RCTs) and uncontrolled before-after studies that evaluated the efficacy of intervention for female sexual dysfunction in women with history of cancer. Methodological quality of studies was assessed using Risk of Bias (RoB) 2.0 for RCTs and National Institutes of Health (NIH) assessment tools for uncontrolled before-after studies.

FINDINGS

Thirty-six studies were included for qualitative synthesis (14 RCTs (n = 1284), 17 uncontrolled trials (n = 589), and 5 cohort studies (n = 497). Only four studies were at low risk of bias. Topical interventions (vaginal gels or creams) were able to alleviate vaginal dryness and dyspareunia, with intravaginal dehydroepiandrosterone (DHEA) (6.5 mg) gel showing evidence of improved sexual function. Evidence for estriol-lactobacilli vaginal tablets was unreliable due to a small-scale study. Psychoeducational therapy (internet-based cognitive behavioral therapy [CBT]) studies typically were at high risk of bias, but all displayed significant improvements of sexual function. Both laser therapy (fractional CO2 and erbium) and multimodal approach studies were at concerning risk of bias, although suggesting beneficial effects on sexual function.

CONCLUSIONS AND RELEVANCE

The most reliable evidence for improvement was from a study of DHEA vaginal gel, but in general, gels or creams were useful in reducing dyspareunia. Pharmacological, psychoeducational, laser therapy, and multimodal approaches demonstrated potential in managing cancer-related sexual issues, but most were small in size (10-70 participants), with moderate to high risk of bias. Therefore, large-scale, double-blind, RCTs with long-period follow-up, and at low risk of bias are needed to show efficacy for these interventions.

Efficacy of intradermal hyaluronic acid plus polynucleotides in vulvovaginal atrophy: a pilot study

OBJECTIVE

This study aimed to evaluate the safety and efficacy of vulvovaginal intradermal injections of polynucleotides (PN) combined with hyaluronic acid (HA) in postmenopausal women affected by vulvovaginal atrophy (VVA).

MATERIALS AND METHODS

Postmenopausal women affected by VVA were treated with vulvar and vaginal intradermal injections of one prefilled syringe of 2 ml PN/HA every 2 weeks for four sessions. Patients were evaluated at T0 (baseline), T1 (after session 4) and T2 (1 month after session 4). Evaluation of the treatment was assessed by three international validated questionnaires: Vaginal Health Index (VHI), Vulvar Health Index (VuHI) and Female Sexual Function Index (FSFI). The Wilcoxon matched-paired signed-rank test was used to compare the differences in VHI, VuHI, FSFI and FSFI domains within the groups. Statistical significance was set at p < 0.05.

RESULTS

Fifty patients were included in the study (mean age 59.9 ± 7.6 years). Overall, the VHI, VuHI and FSFI reported statistically significant differences between baseline and T1 (p < 0.001) and between baseline and T2 (p < 0.001). All FSFI domains registered a statistically significant increase between baseline and T2 (p < 0.001). No complications or side effects were observed.

CONCLUSIONS

Vulvovaginal intradermal injection of PN/HA is a safe, effective treatment, is not expensive and is a reproducible procedure in postmenopausal women with VVA.

Safety of prasterone in breast cancer survivors treated with aromatase inhibitors: the VIBRA pilot study

BACKGROUND

Due to safety concerns on estrogen-based treatments for genitourinary syndrome of menopause (GSM) in breast cancer survivors (BCS), new options are appearing, such as androgen-based treatments, which according to proprieties would not be transformed systemically to estrogens in patients receiving aromatase inhibitors (AIs).

OBJECTIVE

The aim of this pilot study is to assess the security and efficacy of vaginal prasterone (dehydroepiandrostenedione [DHEA]) in BCS treated with AIs.

METHODS

This open, prospective, pilot study included 10 BCS treated with AIs. All participants complained of severe GSM. DHEA was administrated as a vaginal ovule. Participants were instructed to use one ovule every night during the first month, and one ovule every two nights for the entire five remaining months. The patients were requested to attend seriated visits after the beginning of the prasterone treatment to evaluate symptoms, physical improvement and serum estradiol.

RESULTS

Mean serum estradiol remained low from 3.4 pg/ml to 4.3 pg/ml (p = 0.9136) after 6 months of follow-up. The visual analog scale of dyspareunia improved from 8.5 to mean values after treatment of 0.4 (p = 0.0178). The Vaginal Health Index (VHI) scale and Female Sexual Function Index improved from 9.75 to 15.8 (p = 0.0277) and from an initial score of 11.2 to 20.6 (p = 0.0277), respectively. Vaginal pH changed from basal 8.1 to final 6.5 (p = 0.0330).

CONCLUSION

Symptoms and physical examination regarding sexuality and vaginal health improved significantly, while serum estradiol remained at low levels. Prasterone seems a safe and effective option to treat GSM in BCS receiving AIs.

Androgen therapy for women after menopause

Androgens are essential hormones in women. Yet, androgen therapy is understudied and underutilized despite showing improvement in postmenopausal hypoactive sexual desire disorder (HSDD) and the genitourinary syndrome of menopause (GSM). Additionally, regulatory concerns have left a significant gap in commercially available testosterone preparations, formulated specifically for women, in most countries. This has led to off-label use of male formulations and compounded therapies which are under-regulated. Beyond HSDD and GSM, testosterone likely influences the brain, breast, cardiovascular and musculoskeletal systems. These effects are not well studied, and therefore it is difficult to counsel patients on testosterone therapy when used for these endpoints. Ultimately, further study is needed to elucidate these effects, create a fuller picture of the risks and benefits, and encourage product development specifically designed for women.

Vaginal symptoms in women who are affected by gynecologic cancer

PURPOSE OF REVIEW

Pelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer.

RECENT FINDINGS

We review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted.

SUMMARY

Pelvic floor disorders, including vaginal and sexual health concerns, are common in women affected by gynecologic cancer due to both common risk factors and as a side effects of cancer treatment. Gynecologists play a critical role in screening, treatment, and collaboration with other specialists to provide comprehensive care for these women throughout their lifetime.

Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Management of postmenopausal vulvovaginal atrophy: recommendations of the International Society for the Study of Vulvovaginal Disease

OBJECTIVE

To develop a best practice document for the management of postmenopausal vulvovaginal atrophy (VVA).

METHOD

Literature review carried out using clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

There is a wide variety of interventions that may produce temporal benefits for VVA. However, there are significant limitations in scientific publications concerning VVA and related issues, including variable outcome evaluations, variability in population age range, and small, often underpowered sample sizes. Therapeutic management of VVA should follow a sequential order, considering women's age, symptoms, general health as well as treatment preference. Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application. In women with general menopausal symptoms who are candidates for systemic hormone therapy, the lowest effective dose should be used. Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA. Systemic androgens have a limited role. Although laser procedures are commonly used, at this moment the International Society for the Study of Vulvovaginal Disease does not endorse its use out of the setting of clinical trials. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first line therapy. However, limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors. As clinical practice and available preparations vary between countries this text should be adapted to local circumstances.

CONCLUSIONS

There is a wide range of therapeutic options to individualize VVA treatments.

Multifaceted Sexual Dysfunction in Dialyzing Men and Women: Pathophysiology, Diagnostics, and Therapeutics

Patient survival continues to increase with the growing quality of dialysis and management of chronic kidney disease (CKD). As such, chronic therapy must include considerations of quality of life (QOL), and this includes the disproportionate prevalence of sexual dysfunction (SD) in this patient population. This review aims to describe the pathophysiological and the psychosocial causes of SD with regard to renal replacement therapy, particularly hemo- and peritoneal dialysis. The differences in its manifestation in men and women are compared, including hormonal imbalances—and therefore fertility, libido, and sexual satisfaction—the experience of depression and anxiety, and QOL. The impact of comorbidities and the iatrogenic causes of SD are described. This review also presents validated scales for screening and diagnosis of SD in CKD patients and outlines novel therapies and strategies for the effective management of SD. Increased prevalence of CKD invariably increases the number of patients with SD, and it is crucial for health care professional teams to become familiar with the clinical tools used to manage this sensitive and under-quantified field. As a known predictor of QOL, sexual function should become a point of focus in the pursuit of patient-centered care, particularly as we seek to achieve as “normal” a life as possible for individuals who receive dialysis.

Modern management of genitourinary syndrome of menopause

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50–70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO₂ laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

The therapeutic effect of dehydroepiandrosterone (DHEA) on vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a chronic disease that mostly occurs in postmenopausal women. After menopause, insufficient sex hormones affect the anatomy of the vagina and cause drastic physiological changes. The main histopathological studies of VVA show that postmenopausal estrogen deficiency can lead to the increase of intermediate/parabasal cells, resulting in the loss of lactobacillus, elasticity and lubricity, vaginal epithelial atrophy, pain, dryness. Although the role of estrogen hormones in the treatment of VVA has always been in the past, it is now widely accepted that it also depends on androgens. Estrogen drugs have many side effects. So, Dehydroepiandrosterone（DHEA）is promising for the treatment of VVA, especially when women with contraindications to estrogen have symptoms. This review is expected to understand the latest developments in VVA and the efficacy of DHEA.

Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians

Hypoactive sexual desire disorder (HSDD) represents a common condition among transgender women. However, to date no specific guidelines for the management of HSDD in transgender persons are available. The aim of the present narrative Review is to evaluate evidence-based treatment for HSDD and to suggest treatment options for HSDD in transgender women. Clinically relevant publications on the management of HSDD (from 1985 to 2020) were searched in PubMed and Medline databases, using the following terms: "sexual desire", "sexual health", "HSDD", "transgender", "gender-affirming treatment", "sexual therapy", "testosterone treatment", "Central nervous system-active medications", and variants. Since sexual desire could be affected by several factors, a comprehensive assessment of HSDD- exploring biological, psychological, and social domains- is recommended, in order to identify possible predisposing, precipitating and maintaining factors. Among treatment options, transgender women may benefit of different sex therapy strategies and/or central nervous system-active medications-such as flibanserin, bremelanotide, bupropion and buspirone-and transdermal testosterone, bearing in mind that this option could be poorly accepted by patients due to the risk of virilizing effects. The lack of data regarding the efficacy of HSDD treatment options in transgender women emphasize the need for literature to focus more on this topic in the future.

Insight on the Intracrinology of Menopause: Androgen Production within the Human Vagina

In this study, we investigated steroidogenic gene mRNA expression in human vaginas and verified the ability of human vagina smooth muscle cells (hvSMCs) to synthesize androgens from upstream precursor dehydroepiandrosterone (DHEA). As a readout for androgen receptor (AR) activation, we evaluated the mRNA expression of various androgen-dependent markers. hvSMCs were isolated from vagina tissues of women undergoing surgery for benign gynecological diseases. In these cells, we evaluated mRNA expression of several steroidogenic enzymes and sex steroid receptors using real time reverse transcription-polymerase chain reaction. Androgen production was quantified with liquid chromatography tandem-mass spectrometry (LC-MS/MS). In vaginal tissues, AR mRNA was significantly less expressed than estrogen receptor α, whereas in hvSMCs, its mRNA expression was higher than progestin and both estrogen receptors. In hvSMCs and in vaginal tissue, when compared to ovaries, the mRNA expression of proandrogenic steroidogenic enzymes (HSD3β1/β2, HSD17β3/β5), along with 5α-reductase isoforms and sulfotransferase, resulted as being more abundant. In addition, enzymes involved in androgen inactivation were less expressed than in the ovaries. The LC-MS/MS analysis revealed that, in hvSMCs, short-term DHEA supplementation increased Δ4-androstenedione levels in spent medium, while increasing testosterone and DHT secretion after longer incubation. Finally, androgenic signaling activation was evaluated through AR-dependent marker mRNA expression, after DHEA and T stimulation. This study confirmed that the human vagina is an androgen-target organ with the ability to synthesize androgens, thus providing support for the use of androgens for local symptoms of genitourinary syndrome in menopause.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women's past history, symptom severity, and chief complaints.

Postmenopausal Hormone Therapy-Local and Systemic: A Pharmacologic Perspective

Every woman, if she lives long enough, will transition into menopause, and as the US population ages, women will be spending more time in a postmenopausal state than before. For postmenopausal women, the decision to initiate menopausal hormone therapy should be individualized. A thorough evaluation of the patient's cardiovascular, venous thromboembolic, cancer, and fracture risk should be considered along with the woman's quality of life. Hormone therapy exerts its therapeutic effects on vasomotor symptoms, the skeleton, and the genitourinary system independent of age since menopause and these benefits are lost once hormone therapy is stopped. Here we review the pharmacologic properties dose, formulation, mode of administration, timing of initiation, and duration of hormonal therapies in regard to optimizing benefit and minimizing risk to the patient. This discussion will focus on the effects of common hormonal therapies including estrogen (local and systemic), progesterone, estrogen receptor agonist/antagonist, and local dehydroepiandrosterone and include a brief review of compounded bioidentical hormone therapy.

Vaginal dehydroepiandrosterone compared to other methods of treating vaginal and vulvar atrophy associated with menopause

During the menopause, a fall in estrogen levels often leads to many unfavorable symptoms, including changes in the vascular and urogenital systems, in mood, and sleep. The symptoms of vulvovaginal atrophy are especially troublesome for menopausal women. These symptoms not only disturb the sexual sphere, but also functioning at work and in the family. Based on the literature, a review of contemporary methods of management in the case of symptoms of vulvar atrophy in menopausal women has been performed. The current methods of treating vulvovaginal atrophy in menopausal women are described. The pharmacology of the available dehydroepiandrosterone (DHEA) preparations, both oral and vaginal, was briefly analyzed. Own experiences of using DHEA are presented. Vaginal DHEA has been found to be an effective and safe treatment in menopausal women with symptoms of vaginal atrophy.

A randomized, double-blind, placebo-controlled trial of testosterone for treatment of postmenopausal women with aromatase inhibitor-induced arthralgias: Alliance study A221102

PURPOSE

To evaluate the efficacy of testosterone supplementation for improving aromatase inhibitor musculoskeletal symptoms (AIMSS).

METHODS

Postmenopausal women experiencing moderate-to-severe arthralgias while taking adjuvant aromatase inhibitors for breast cancer were enrolled in this trial. Initially, patients were randomly allocated to receive either a subcutaneous testosterone pellet versus a placebo pellet. Due to slow accrual, the protocol was modified such that additional participants were randomized to receive either a topical testosterone gel or a placebo gel. Changes in patient-reported joint pain were compared between patients receiving testosterone and those receiving placebo using a two-sample t test. Changes in hot flashes and other vasomotor symptoms were also analyzed. Further analyses were conducted to evaluate whether 27 single nucleotide polymorphisms (SNPs) in 14 genes previously associated with AIMSS were associated with testosterone supplementation benefit.

RESULTS

While 64% of patients reported an improvement in joint pain at 3 months, there were no significant differences in average pain or joint stiffness at 3 or 6 months between testosterone and placebo arms. Patients receiving testosterone did report improvements in strength, lack of energy, urinary frequency, and stress incontinence (p < 0.05). The subset of patients receiving subcutaneous testosterone also experienced improvements in hot flashes and mood swings. An inherited variant (rs7984870 CC genotype) in TNFSF11 was more likely to be associated with improvements in hot flashes in patients receiving testosterone.

CONCLUSION

The doses of testosterone supplementation used in this study did not significantly improve AIMSS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01573442.

Management of genitourinary syndrome of menopause in female cancer patients: a focus on vaginal hormonal therapy

Genitourinary syndrome of menopause is a condition describing the hypoestrogenic effects on the female genitals and lower urinary tract leading to symptoms such as vaginal dryness, vulvar and vaginal burning, dyspareunia and dysuria. Genitourinary syndrome of menopause is experienced by over half of postmenopausal women, and is even more pervasive in women with cancer. Due to treatments such as surgery, chemotherapy, radiation, and hormonal therapy, women may experience early menopause resulting in earlier and more severe symptoms. Understanding the scope of this issue in female breast and gynecologic cancer survivors and identifying treatment options for this complex patient population are paramount. Tailored patient treatments include nonhormonal therapies (vaginal moisturizers, lubricants, pelvic floor physical therapy, dilator therapy, counseling), systemic and local hormonal therapies. Consensus recommendations by medical societies and associated evidence are reviewed, with emphasis on safety and efficacy of local vaginal hormonal therapies, and management variations noted depending on cancer type and characteristics. With knowledge and understanding of the unmet need associated with under-recognition and under-treatment of genitourinary syndrome of menopause, providers caring for women with cancer are in a position to improve the quality of life of their patients by providing safe and effective treatments.

Effect of the Fractional CO2 Laser on the Quality of Life, General Health, and Genitourinary Symptoms in Postmenopausal Women With Vaginal Atrophy: A Prospective Cohort

Introduction: After menopause women experience vaginal atrophy related to hormonal changes and estrogen deficiency. The purpose of this paper was to evaluate the effect of the fractional CO₂ laser on the quality of life, vaginal atrophy symptoms, and urine incontinency in menopause women. Methods: This prospective study was conducted among 140 women from 2017 to 2018 in Yas hospital, Tehran University of Medical Sciences. They encountered the fractional microablative CO2 laser system three times at four-week intervals. The short form of the Health Questionnaire (SF-12) and the Female Sexual Functional Index (FSFI) questionnaire were utilized to assess the participants' quality of life. Also, the standard measuring tools including the vaginal health index (VHI) and International Consultation on Incontinence Questionnaire (ICIQ) Form were used to evaluate the vaginal atrophy symptoms. Results: The quality of life improved significantly in somatic, social function, and mental health. In the sexual context, arousal and satisfaction status improved significantly. Also, the frequency of urinary incontinence, enuresis, urgency, and the leak improved significantly (P<0.05). Among the scale variables for urinary function, it was seen that the urgency impact had no improvement. All vaginal indices improved (P<0.05). Conclusion: The fractional CO₂ laser can be effective in treating vaginal atrophy and urinary symptoms. Besides, it improved the quality of life and the sexual function of post-menopausal women.

Vaginal Health in Menopausal Women

The aim of this review is to provide an overview of genitourinary health in peri- and postmenopause, particularly of vulvovaginal atrophy (VVA), which is part of genitourinary syndrome (GSM). This condition has a high prevalence among post-menopausal women and negatively affects a woman's quality of life. Epidemiology, signs, symptoms, diagnostic criteria of VVA and target treatments for restoring vaginal health are discussed in light of the most recent literature. Issues related to this condition in menopausal women are under-diagnosed, lack objective diagnostic criteria, and consequently under-treated. Over the years, many treatments have been developed but their long-term effectiveness and safety have yet to be clearly defined. Patients are often dissatisfied and stop treatment, suggesting the need for a more personalized and tailored approach to achieve better compliance and thereby effectiveness. The aim of this paper is to provide an overview of the most recent literature on VVA in order to help the gynecologist in the management of this condition.

Menopause: Hormones, Lifestyle, and Optimizing Aging

Although American women spend approximately 30% to 40% of their lives in menopause, a state defined by the cessation of estrogen production by the ovaries, obstetricians and gynecologists in North America receive little formal education about menopausal health. Hormonal therapy has been available for more than 75 years; however, controversies surrounding its use have impacted training of care providers in all specialties. This article offers updates on care for menopausal women, focusing on symptomatology and health issues that arise related to the decline in all reproductive hormones. Lifestyle adaptations and nonmedical approaches, and nonhormonal and hormonal medications are discussed.

Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function

The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.